As a medical oncologist and palliative care physician, I’ve had the privilege of caring for cancer patients and delivering primary palliative care and symptom control, as well as the chance to care for patients especially referred for complex pain and symptom problems (in secondary and even tertiary care).1 This work is tremendously gratifying, but I can assure you that it is humbling.
Pain management often sounds fairly straightforward when explained to patients with cancer. If you visit the National Cancer Institute’s website (www.cancer.gov), for example, you find that “People who have cancer don’t always have pain. Everyone is different. But if you do have cancer pain, you should know that you don’t have to accept it. Cancer pain can almost always be relieved.” Pain management sounds easier here than it really is.
What makes cancer pain management challenging? One reason is that there are no validated biomarkers to help physicians tailor therapy to individual patients. As such, pain care is based on rigorous assessment and reassessment and the use of time-limited therapeutic trials of analgesics (and sometimes pain procedures).
Getting the best results in pain management requires excellent communication and negotiation skills to establish a therapeutic alliance and get buy-in from patients and family members. It also entails painstaking education and teach-back methods to assess understanding. And the best results come from multidisciplinary teams of skilled clinicians (including nurses, pharmacists, social workers, and others).
Revealing Studies
In 1994, Dr. Charles Cleeland and colleagues published a landmark paper in The New England Journal of Medicine showing that two-thirds of patients with metastatic cancer have pain, and 42% of those patients are undertreated if you use the pain management index as the indicator of appropriate analgesic prescribing.2 This brought attention to the problem of pain, but the attention was focused on finding cancer patients who were having pain.
The idea was that pain should be the fifth vital sign, and it was thought that once unmasked, pain was readily manageable. After all, this landmark study was cross-sectional, and one might figure that if there had been follow-up data, nearly all of these patients would have been treated and would improve over a short time frame.
Based on our humbling clinical experiences, most oncologists knew better. The SOAPP study (Symptom Outcomes And Practice Patterns) conducted by the Eastern Cooperative Oncology Group and two pain-related papers published in the Journal of Clinical Oncology certainly show this.3,4 Even when the cohort of ambulatory cancer patients is not limited to patients with metastatic cancer, we still find that two-thirds of patients have pain or require analgesics, and only one-third get adequate analgesic prescribing.
In the recent Zhao et al SOAPP publication in the Journal of Clinical Oncology—reviewed in this issue of The ASCO Post—we find what happens when we follow patients over a 4- to 5-week period after initial assessment.4 They do not all get better. About one-third significantly improve, but one-fifth get worse and 28% of those who didn’t have pain subsequently develop pain (9% of them in the moderate-to-severe range).
These are patients being followed on a study where their pain and symptoms are being actively recorded and carefully watched by teams that are actively involved in cancer research. One might expect this to be the best-case scenario. So now we know just how inadequate pain management can be, and these data can be used to adjust our language about the success of pain treatment and to motivate us to find ways to improve care.
Challenges and Solutions
Among the findings reported by Zhao et al, we note that the biggest barrier to improving pain is the obvious factor, the undertreatment of pain. Other factors make clinical sense, too. Constipation, coprescribing of multiple drugs, and unemployment all represent barriers to adherence to opioids prescribed for pain control. Neuropathic pain is an adverse predictor, and this type of pain is famously less responsive to commonly prescribed (and less expensive) analgesics like acetaminophen, nonsteroidal anti-inflammatory agents, and opioids. And community institutions were less successful than academic institutions in pain control, perhaps an issue related to having less access (on average) to pain and palliative care specialists.
How could cancer pain care improve such that the next prospective cohort study yields a much brighter set of data? First and foremost, better drugs and procedures for cancer pain are needed. Progress in this regard requires many more investigators to be involved in studying basic mechanisms of cancer pain. Change in this regard will require more funding to build this workforce.
Another element of change would be in the realm of incentives. Better reimbursement for clinicians to counsel patients about the goals of care and options and barriers related to pain management would allow for better staffing and staff training in this realm. Educational reform and health-care delivery reform that enhance the early integration of palliative care would make a big difference in outcomes, too.5 The elements of palliative care generally build toward overcoming barriers to pain management.
Routine Quality Measures
Finally, incorporation of routine quality measures related to pain management and transparent reporting of such data would enhance the focus of individuals and organizations on pain management. Such quality measures need to go beyond just documenting pain.
For example, in our Regional Cancer Centers, oncologists are participating in the Quality Oncology Practice Initiative (QOPI), and their citizenship metrics (and pay) are affected by their performance in terms of documenting a plan of care for moderate/severe pain by the second office visit. This is a part of a new model and a trend in oncology toward identifying and rewarding performance that goes beyond standard measures of productivity and includes a focus on aspects of performance that have high impact on patients.6 Ultimately, the goal we all seek with these individual, organizational, and health policy efforts is to make an impact on patients’ lives. Improving the care of cancer pain would certainly be a good place to start. ■
Dr. Fisch is Chairman of the Department of General Oncology and Medical Director of the Community Clinical Oncology Program Research Base, The University of Texas MD Anderson Cancer Center, Houston.
Disclosure: Dr. Fisch reported no potential conflicts of interest.
References
1. von Gunten CF: JAMA 287:875-881, 2002.
2. Cleeland C, et al: N Engl J Med 330:592-596, 1994.
3. Fisch MJ, et al: J Clin Oncol 30:1980-1988, 2012.
4. Zhao F, et al: J Clin Oncol 32:312-319, 2014.
